Pediatric Otolaryngology ENT emergencies
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1 Pediatric Otolaryngology ENT emergencies 天主教耕莘醫院耳鼻喉科台大醫院耳鼻喉部兼任主治醫師 Pediatric Laryngology Size : vocal process.. 等構造相對較大 Morphology : 漏斗型 Position : 相對比成人高 Tissue character : 較軟 (floppy) 王守仁醫師 Cuneiform cartilage Morphology
2 Position Newborn Adult C2 C2 C4 C4 C6 E:epiglottis S:soft palate 軟喉症 (Laryngomalacia) 最常見的先天性喉部異常 吸氣性的喘鳴 (inspiratory stridor) 仰臥 哭鬧或上呼吸道感染時會加劇 俯臥 睡覺及休息時會減輕 大多在一歲半左右症狀會自然消失 雷射燒灼杓會厭皺折 (A-E fold) 上呼吸道阻塞 餵食困難 Laryngomalacia Ω
3 Tissue Targeted by Supraglottoplasty Adenoid vegetation Adenoiditis Infected adenoid tissue (URI) nasal obstruction, purulent rhinorrhea, postnasal discharge, cough, and fever nonspecific, mimic APS antibiotics, mucolytics, etc. AOM, otitis media with effusion (OME) Nasopharynx 鼻咽部 - Exam Adenoid vegetation 腺樣體增殖症
4 LIGHT Local examination Skull lateral view Adenoidectomy Obstruction Obligate mouth breathing Sleep apnea and/or sleep disturbances Infection Recurrent/chronic adenoiditis Recurrent/chronic OME Neoplasia
5 ENT emergencies 耳 鼻 咽喉及氣管食道異物 (Foreign body) 鼻出血或其他頭頸部出血 (Bleeding) 急性上呼吸道阻塞 (Acute Upper Airway obstruction) 外傷引起的頭頸部症狀 (Trauma, Maxillofacial Injury) 咽喉深頸部感染 (Deep neck infection) 誤食 誤吸或自殺導致化學性氣道 消化道灼傷 (Corrosive or Inhalation injury) 眩暈症 (Vertigo) ENT emergencies Esophageal foreign body Ear bleeding Acute epiglottitis Deep neck infection Esophagology : FB removal Four narrowing Cricopharyngeal muscle : 16cm Aorta : 23cm Left main bronchus : 27cm Esophageal hiatus: 36cm from upper incisor 胃 裂孔 : 36cm 支氣管 : 27cm 大動脈 : 23cm 環咽肌 : 16cm 上門牙
6 硬式食道鏡 50cm Ear Bleeding Acute Epiglottitis Maxillofacial injury, Head injury (Skull base fracture), Temporal Bone fracture, External ear canal trauma Otoscopic examination Facial paralysis (WHY?) Skull X-ray, Mastoid X-ray, Brain CT scan, High resolution temporal bone CT scan Ear packing? Ear wick, gauze, iodoform Explanation of persistent bleeding Acute supraglottic laryngitis Bacterial or virus infection Haemophilus influenzae Decreased in child cases after Hib vaccine Increased in adult cases (Gr. A Streptococcus) A true ENT emergency Symptoms of Acute Epiglottitis Sore throat or odynophagia (100%) Fever and/or chillness (88%) Dysphagia (76%) Hoarseness or muffled voice (54%) Dyspnea, stridor, orthopnea (38%) Drooling (10%) Neck tenderness, referred otalgia, etc Diagnosis of Acute Epiglottitis Auscultation Neck lateral soft tissue X-ray Indirect laryngoscopy Fiberoptic laryngoscopy Neck CT scan
7 Thumb sign Management of Acute Epiglottitis Artificial airway Close monitoring in ICU Incision & drainage (scarification) Parenteral antibiotics Inhalation Steroid? Deep neck infection Infection in the deep neck spaces Neck spaces: divided by cervical fascia Cervical fascias: Superficial cervical fascia Deep cervical fascia: superficial layer middle layer deep layer Neck Spaces & Cervical Fascias Superficial fascia invests the platysma muscle Deep fascia Superficial (red) Middle muscular division visceral division Deep layers (prevertebral fascia) Etiology Odontogenic Tonsillitis IV drug injection Trauma Foreign body Sialoadenitis Parotitis Osteomyelitis Epiglottitis URI Iatrogenic Congenital anomalies Idiopathic
8 Clinical presentation Sore throat Odynophagia Neck swelling Neck Pain Suprahyoid region Parapharyngeal space S- superior : skull base I- inferior : hyoid bone A- anterior : ptyergomandibular raphe P- posterior : prevertebral fascia M- medial : buccopharyngeal fascia L- lateral : superficial layer of deep fascia Parapharyngeal space Prestyloid Muscular compartment Medial tonsillar fossa Lateral medial pterygoid Contains fat, connective tissue, nodes Poststyloid Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain Parapharyngeal Space Communicates with several deep neck spaces. Parotid Masticator Peritonsillar Submandibular Retropharyngeal Parapharyngeal space infection Fever, chills, malaise Pain, dysphagia, trismus Medial bulge of lateral pharyngeal wall Cause: infection of pharynx, tonsil, adenoids, dentition, parotid, mastoid, suppurative lymphadenitis, extension from other deep neck spaces Parapharyngeal space infection Cellulitis state: medical treatment Abscess formation: medical treatment + surgical intervention
9 Take Home Message - 1 High risk group Old age DM Underlying systemic disease High prevalence rate of DM (30%) Deep neck infection: analysis of 185 cases. Head Neck 26: , 2004 Take Home Message - 2 Three leading organisms Streptococcus viridans K. pneumoniae: strongly associated with DM Peptostreptococcus Management Airway protection Antibiotics Surgical drainage: open vs. minimal invasive Airway protection Endotracheal tube (intubation) Cricothyroitomy Tracheostomy skin, subcut. tissue strap muscle thyroid gland pretracheal fascia Parapharyngeal space Parotid space ~18 Wound: 4cm, Penrose 6cm inserted Left SCM, Submandibular, Parotid spaces
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